Creating strong, durable provisionals

The rising demand for elective and implant-based dental treatments has led to a direct increase in the use of temporary restorations.1 Properly fitted and reliable, patients benefit from the utility and esthetics that provisional materials offer.1 Further, dentists rely on provisionals to prevent deterioration of hard and soft tissues of the oral cavity while patients await the definitive restoration.1

The rising demand for elective and implant-based dental treatments has led to a direct increase in the use of temporary restorations.1 Properly fitted and reliable, patients benefit from the utility and esthetics that provisional materials offer.1 Further, dentists rely on provisionals to prevent deterioration of hard and soft tissues of the oral cavity while patients await the definitive restoration.1

Critical to the success of many restorative procedures, provisional restorations may be required for two weeks, 12 months or more.1 Therefore, strong and durable provisional materials are necessary to enable the patient to function in the long-term.1

Providing a solution, Telio, a new provisional material system from Ivoclar Vivadent, was developed to address the needs of dentists, technicians and patients. The provisional system features three material lines, including Telio CAD, Telio CS, and Telio Lab, which offer shade and material compatibility in a variety of cases.2 Additionally, the provisional material system enables collaboration and enhanced communication of case requirements between the dental team throughout all treatment phases.2

Telio CAD acrylate polymer (PMMA) blocks can be CAD/CAM processed into long-term temporary crowns and bridges.2 This material has been formulated to eliminate challenges often associated with traditional provisional restoration fabrication, including polymerization shrinkage, impression defects, mixing errors and clean-up.2 Further, Telio CAD demonstrates durable shade stability and lifelike fluorescence to ensure a naturally appearing result.2,3 Additionally, the provisional material offers more than 130 MPa flexural strength and more than 3,200 MPa flexural modulus.4 Durable and flexible, the material is ideal for clinical situations requiring long-term provisionalization.2

Available in 6 shades and bridge sizes with up to two parties, Telio CAD blocks are indicated for a variety of provisional restorations, including temporary anterior and posterior crowns, bridges (up to two pontics), temporization of implants, provisional restorations that correct temporomandibular joint (TMJ) disorders, and occlusal adjustments.3,4

Case presentation

A 24-year-old male patient presented to the office after suffering an injury while playing basketball. Another player drove his elbow into the patient’s face, resulting in tooth No. 21 becoming completely intruded. Two-stage surgery was completed with the tooth extracted and an implant placed (Fig. A). Although a success, some bone and soft tissue deficiencies remained after implant therapy.

The treatment plan included placing a temporary crown on tooth No. 21 and an implant-supported crown on tooth No. 11. The crown would provide a scaffold for a connective tissue (CT) graft that would be completed in the near future when the tissue matured further. However, a laser gingivectomy was initially completed to raise tissue height prior to placing temporary crowns. A semi-final impression would then be taken at the second stage of surgery and the tissues would be pulled down into proper position.

In this case, Telio CAD was chosen as the long-term provisional material. It would allow the soft tissues to heal into proper form, while providing a scaffold for the connective tissue graft.3,4

Clinical Protocol

Prior to provisionalization, the patient was anesthetized. Gingival recontouring was then completed around the affected dentition with a soft-tissue diode laser (Odyssey, Ivoclar Vivadent) (Fig. B). After recontouring, impressions were taken of the patient’s dentition and soft tissues. The initial shade of the provisional restorations was then determined using a shade tab. Once complete, all necessary case information was sent to the laboratory for fabrication of provisional crowns.

Laboratory Protocol

All diagnostic information was received by the laboratory, models were poured, and the case mounted on a semi-adjustable articulator (Fig. C). The dentist requested a long-term provisional restoration for tooth No. 21 and an implant-supported provisional crown on tooth No. 11. Therefore, the provisional restorations were CAD/CAM (NobelProcera™) processed from Telio CAD, a strong and highly esthetic temporary material that would allow the patient’s gingival tissues to heal.

01 To fabricate the provisional restorations, the NobelProcera CAD/CAM system (Nobel Biocare®) was chosen because it offers greater versatility in designing and milling the case. Offering minimal scanning and designing time, the system also enables the technician to add to the restorations easily after milling. This ensures the proper emergence profile and highest esthetics can be achieved simply and efficiently.

02 Prior to scanning, a plastic engaging temporary abutment was placed on the model and trimmed to fit inside the crown. The case was then scanned into the CAD/CAM system with a highly accurate and easy-to-use NobelProcera scanner. The provisional restorations for tooth Nos. 21 and 11 were then designed, along with the preparation margins (Fig. D). The NobelProcera CAD/CAM software suggested two provisional crowns for proper restoration (Figs. E and F).

03 The Phonares shade and form (Ivoclar Vivadent) of the provisional restorations were selected from the tooth mould library within the NobelProcera 3D CAD/CAM software. The handle and other tools in the three-dimensional CAD/CAM design software were then used to place the crowns in ideal position. The provisional restorations were carefully designed to ensure stability and a blueprint for final restorations. After the case was designed, all necessary information was sent to the NobelProcera manufacturing facility. At the facility, the provisional restorations were milled from PMMA highly esthetic and durable acrylate polymer block and Telio CAD. The crowns were milled as a splinted unit and returned to the laboratory for characterization after only two days.

04 Upon receiving the completed provisionals, the crowns were tried on the model to evaluate accuracy and fit (Fig. G). After confirmation of fit, a putty-matrix was created of the crowns on the model to ensure uniform cut-back of the dentin layer of the material. Using the putty matrix, the crowns were cut-back to achieve the proper emergence profile (Figs. H and I). Further, the cut-back provided room for the addition of staining and build-up materials to achieve a naturally appearing result.

05 Prior to staining, SR Composiv adhesive agent (Ivoclar Vivadent) was extruded from the syringe and placed directly on the bonding surface in an 0.2 mm to 0.5 mm increment. The adhesive was added to provide a strong bond between the dentin and light curable stains that were applied. After, the adhesive agent was light cured, internal modifiers and enamel layering stains were added to the crowns to match the patient’s surrounding dentition (Fig. J). To achieve final contour, Telio Lab flowable staining material (Ivoclar Vivadent), in shade Transpar Incisal 1, was then added to the provisional crowns.

06 Once staining was complete, the implant crown was affixed to the abutment with Telio Add-On Flow flowable composite (Ivoclar Vivadent) and light cured. The splinted crowns were split and contacts were added using Telio Add-On Flow. A hole was drilled slightly lingual to the incisal edge to ensure the implant crown could be screw-retained (Fig. L). The completed provisionals were finished with a carbide bur and polished with rubber and silicone polishers.

07 Upon completion, the crowns were placed on the model and evaluated for proper fit (Fig. K).The crowns were then delivered to the clinician for final seating.

Seating

The crowns were received from the laboratory and placed on the model to confirm accuracy (Fig. M). The tooth surfaces were cleaned and dried in preparation for seating. To prepare the Telio CAD restorations, the internal surfaces were abraded with 100 µm Al2O3 at 1-2 bar pressure. Telio CS Link dual-curing temporary composite cement (Ivoclar Vivadent) was placed on the internal surfaces of the provisional crown. The crown was seated in position, excess cement removed, and the cement light cured. The implant-supported crown was seated and secured with the implant screw. Cotton was used to cover the implant screw access hole and temporary cement was used to seal the screw hole.

Upon completion of the case, the NobelProcera CAD/CAM processed Telio CAD provisional crowns demonstrated excellent fit, function and lifelike esthetics (Fig. N).

Conclusion

Using an innovative CAD/CAM processed provisional material, the dentist and technician were able to provide the patient with a strong, durable and esthetic restoration to allow his gingival tissues to properly heal and provide a scaffold for a future connective tissue graft. The provisionals would ultimately provide the stability required to prevent further hard- and soft-tissue loss, while allowing the patient to function and appear normally.1 Offering many advantageous features, innovative materials like Telio CAD provide greater durability, strength and esthetics, even in cases requiring long-term provisionalization.1-4

About the author

Christian Hall, RDT, graduated from Saint Mary’s University before following in his father’s footsteps at Hallmark Dental Laboratory Ltd., Halifax, NS. Now in its 30th year, Christian is a second generation owner of the lab, which specializes in both removable and fixed Implant prosthetics. Christian has a passion for continuing education, always striving to be better, and is proud to be a vital part of the entire restorative team having close communication with his clinicians.